DAR NOTE

Patient: [Full name]
Date of birth: [Date]
Location: [Unit, room, and bed]
Date and time of entry: [Date, and the time the care happened]
Late entry: [Time written, if charted after the event, or not a late entry]
Nurse: [Name, credentials]

FOCUS
Focus: [One concern in a few words: a patient concern, a sign or symptom, a change in condition, a nursing diagnosis, an event, or a teaching need; not a medical diagnosis]
Care plan link: [The care plan problem or goal this entry relates to, or none]

DATA
What the patient said: [Subjective data, quoted where the words matter]
What you found: [Assessment findings, vital signs, and scores with the tool named]
Context: [Baseline, recent medications or treatments, and what led to this entry]

ACTION
Nursing interventions: [What you did, with times; drug, dose, and route for any medication]
Notified: [Name and role, time, what you reported, and the orders or advice received]
Teaching: [What was taught, to whom, and how, such as demonstration or teach-back]
Safety and comfort measures: [Precautions put in place]
Reassessment due: [When, and with what measure, you will check the response]

RESPONSE
Time reassessed: [Time]
Patient's response: [Findings after the action, using the same scale or measure as in Data]
Patient's words: [What the patient said, where it shows the response]
Goal: [Met, partly met, or not met, and the goal it was measured against]
Next step: [Continue, change the plan, escalate, hand over, or resolve the focus]

NEXT FOCUS
Copy the Focus, Data, Action, and Response block for each new concern or follow-up entry.

Signed: [Nurse name, credentials, date and time]